Forms Archives - Frank Batastini Orthodontics

ACH Authorization

May 14, 2020 by digitalx

Dr. Frank Batastini Orthodontics ACH Authorization Form.
Please note, functions of this form have been disabled due to the nature of the form. Please call our office to pass along your information to our office staff.

Name*
First Middle Last
Address*
Street Address Address Line 2 City State ZIP Code
Home Phone*
Work Phone*
Last 4 Digits of Social Security #*
Drivers License #*
Drivers License State*
Payment Plan Schedule
Plan Choice*
- One Time Payment
- Recurring Debt
Payment Amount*
Payment Date*
Frequency Every:*
Please enter a value between 1 and 31.
Timeframe
Start Date*
End Date
Payment Amount
Transaction Fee
Customer Bank Account Information
Bank*
Bank Phone*
Payment Authorization
Authorization*
- I authoize
I authorize my bank to debit my account as identified above to the terms stated here. This authorization shall remain in effect until the Service Provider and bank receive written notification from me of intent to terminate at such time and in such manner as to afford the Service Provider and bank reasonable opportunity to act (Minimum 30 days). I understand that if the total amount owed to the Service Provider is increased, I authorize this plan to continue as long as the payment amount remains unchanged until the amount owed the Service Provider is paid off, or unless the plan is terminated earlier by me as above. I understand any added amounts can be applied for with a new ACH Debit Authorization Form. All other changes such as payment amount, frequency, bank account number change, will require a new ACH Debit Payment Authorization Form to be filled out and submitted to Merchant 15 days prior to any change being implemented. I understand that this payment plan may be cancelled by the Service Provider or Merchant due to NSF (Non-sufficient Funds). I will be liable to pay an NSF fee of $25.00 (or the amount allowable by law), which may be automatically debited for each NSF. I represent and warrant that I am authorized to execute this payment authorization for the purpose of implementing this payment plan. I indemnify and hold the Service Provider, the bank, and Merchant harmless from damage, loss or claim resulting from all authorized actions hereunder.
Name*
First Last
Date*

Patient Health Form

May 14, 2020 by digitalx

Dr. Frank Batastini Orthodontics Patient Health Form

HIPPA Form

May 14, 2020 by digitalx

HIPPA / Consent Form

Patient Giving Consent*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone*
Email*
To The Patient
Please Read the Following Statements Carefully
By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.
You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent. We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain. You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting: Contact Person: Sherry Beatty Telephone: 856 262-0500 Fax: 856 262-1130 E-mail: FBortho@drfrankortho.com Address: 188 Fries Mill Rd., Turnersville, NJ 08012
You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.
During you or your child’s treatment time here at Dr. Frank Batastini Orthodontics, there may be certain moments where photographs may be taken. These photos may be used on our website or in our offices for promotional use. We will never sell these photographs or provide them to a third party source. Please acknowledge below if you allow or do not allow consent for us to take photographs for promotional use.
Photograhy*
- Allow
- Do Not Allow
Please check your consent option
I Have Read...*
- I have read and acknowledge
By checking this box, I acknowledge that I have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by checking this box on this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and heath care operations.
Name*
First Last
Entering your name constitutes a signature
Date*
If this Consent is signed by a personal representative on behalf of the patient, complete the following:
Personal Represntantive Name
First Last
Relationship to Patient

Payment Plan Schedule

Customer Bank Account Information

Payment Authorization

To The Patient